Interview with Dr. Wadih Naja

Professor of psychiatry with several subspecialties, Dr. Wadih Naja obtained his M.D. degree from Saint Joseph University (USJ) in 1991.

Following his graduation, Dr. Naja completed a 4 years residency training in Psychiatry at the faculty of Medicine of South Paris, followed by several trainings in Pharmacology of Psychotropic Drugs and Forensic Psychiatry at the Faculty of Medicine of South Paris and the Faculty of Medicine of La Pitié Salpetrière.

Dr. Naja then returned to Lebanon to embark in his clinical career. In 2003, he joined Rizk Hospital, and then, in 2006, he became part of the department of psychiatry in Mount Lebanon Hospital.

In 2008, Dr. Naja became, the head of department of psychiatry at the faculty of Medicine of the Lebanese University (UL) until 2017. He was nominated as Professor in 2016.  He was also the president of the Lebanese Psychiatric Society between 2017 and 2019.

Dr. Naja is one of the cofounder of LAMSA and was part of LAMSA’s board between 2013 and 2016, tremendously helping with LAMSA’s debut in mental health awareness.

LAMSA: First of all, thank you Dr. Naja for giving our cause your precious time!

As a start, we know that schizophrenia is common in the US, 1.1% of the population. Is schizophrenia as common in Lebanon?

Dr. Naja: There are no recent epidemiological studies done in Lebanon regarding schizophrenia. The latest study was published in 2008 in PLOS Medicine. This study showed the lifetime prevalence of mental disorders in Lebanon. It proved that Lebanon had the same figures as worldwide: around 1 to 1.2% of the Lebanese population were affected by schizophrenia, which is the lifetime prevalence rate of schizophrenia worldwide.

LAMSA: Do patients come directly for a consultation when the symptoms start? Or do you see severe cases due to the fact that this subject is taboo in Lebanon and that some families try to hide or deny the facts at first?

Dr. Naja: Well, the taboo subject around mental illness is starting to fade with time thanks to globalization, internet, and education. Awareness campaigns like the one LAMSA and other NGOs are doing is helping a lot. There are 2 main problems regarding schizophrenia. The first aspect is the lack of insight: most of our patients who suffer from schizophrenia lack insight, known as anosognosia, meaning they are not aware that they are sick. Therefore, patients won’t call for an appointment and ask for help on their own. In the majority of cases, the family calls and books for an appointment and brings over their child, son, daughter, wife, mother… And yes, unfortunately, there is still some gap between the onset of symptoms and the time they visit the doctor. Here as well, anosognosia plays a role because often the patient refuses to come to the consultation with his family.
The second problem is that the symptoms often start in adolescence and parents tend to explain them as a problem related to adolescence which can lead to a delay between onset of symptoms and time of consultation.

LAMSA: What are the common misconceptions that families in Lebanon have with respect to the disease?

Dr. Naja: The most common misconception is that this is something related to the environment. Of course, environmental factors are important such as the use of weed and cannabis, the separation from the family and going abroad where they will be confronted with acculturative stress … However, there is also a genetic component to the disease. It is important to explain to the family that there is a genetic basis to this disease and that it is not a bad parenting issue or a family conflict issue. Parents in fact sometimes feel guilty thinking they are the reason their child has schizophrenia; this is not true.

LAMSA: How do families in Lebanon react to a diagnosis of schizophrenia in one of their family members?

Dr. Naja: The main concern families have is: “when will the patient stop the treatment?” Often, the main concern is not the disease but the medications. This is sad because it is a fallacy that psychiatric medications are toxic medications. Yes, psychiatric medications do have side effects but no more nor less than medications used for rheumatoid arthritis, cardiovascular diseases or any other disease. The second fallacy regarding treatment is that the medications are addictive. Well, if long term treatments are put under the umbrella of addictive medications because you should not stop taking these medications, then you might say that psychiatric medications are addictive. But, in medicine, outside of microbiology (bacteria, viruses and parasites), there are very little diseases which you expect the patient to stop the medication: metabolic diseases like diabetes, cardiovascular diseases like hypertension, epilepsy, asthma, rheumatoid arthritis, inflammatory diseases… Medicine is all about lifetime medications. However, having diabetes and taking insulin doesn’t mean the patient is addicted to insulin. Having hypertension and taking beta blockers doesn’t mean the patient is addicted to beta blockers. Yet, you have to take these medications for a lifetime. Same goes for psychiatric medications. The discrepancy appears when relatives of the patient say that psychiatric medications have a lot of side effects and are addictive, but they are the ones who have other chronic conditions which need lifetime medications. However, those relatives don’t argue with the doctor to stop the insulin or the beta blocker like they argue with the psychiatrist. Also, the first question they would ask the physician in case of any other disease is “When will my father get cured from cancer or ulcer?” But when it comes to a psychiatric condition, unfortunately, the common question being asked is “When will my son stop the medication” and not “When will he be cured from the disease”. Even after explaining that 70% of the patients diagnosed with schizophrenia, which is a dangerous condition that can destroy one’s life, will substantially improve, the families’ main concern is medication and not the disease itself.

LAMSA: What is offered to patients with schizophrenia in Lebanon? Do we have a special center for the care of this condition?

Dr. Naja: We don’t have a specialized center oriented for the sole treatment of schizophrenia in Lebanon. However, the psychiatric medications that you find worldwide are available in Lebanon. Fortunately for us, the Ministry of Public Health still covers some of the expensive medications. This helps significantly because many patients are unable to attend a job and often rely on the financial help of their families. The cognitive-behavioral therapists are sensitive to schizophrenia and some are very skilled to provide care for schizophrenia patients. Psychoeducation regarding the medication, the genetic basis and the reintegration into social life is the mainstay of the treatment of schizophrenia and this is the role of psychologists. However, not many psychologists are trained in cognitive remediation. Finally, to my knowledge, there was the premise of some group therapy, but this has not yet been developed.

LAMSA: After the event on August 4^th and following the COVID-19 pandemic, have you seen an increase in schizophrenia cases?

Dr. Naja: De novo schizophrenia cases most probably have not increased in number. The rate is still around 1.1% of the Lebanese population although we don’t have statistics to scientifically prove that. However, some patients who were already diagnosed with schizophrenia have seen an exacerbation in the severity of their symptoms due to several reasons. First, patients are having a hard time getting access to the medications due to the economic crisis in Lebanon because medications are becoming scarce. Second, due to COVID-19, social distancing also had a toll on the severity of the symptoms.  Fortunately, telemedicine is taking a chunk of treatment and consultations whether with the psychiatrist or the psychologist. Patients can have access to medical care that way. Substance abuse and alcohol abuse is rising because the more you are confined the more patients resort to alcohol and drugs. All these have led to the worsening of the mental condition of patients who already suffer from schizophrenia rather than the appearance of de novo cases.

LAMSA: Do you think that LAMSA’s awareness campaign is important?

Dr. Naja: I think what you are doing is great. I sometimes follow you on Twitter so I get to read what has been done. You know that schizophrenia is a disease that hits mainly people who are less than 27 years old and the symptoms usually start in adolescence and early adults. Young people are oriented and sensible to social media. This makes your messages on social media reachable to this specific population. Congratulations for that! You know, psychotic and schizophrenic patients tend to have poor social skills and resort to social media so this is where you can target them. Your messages on social media also help shed a light on the scarcity of the medications in these hard times for Lebanon. One thing I would like to add is that we are also having a hard time finding COVID-19 units who would take patients with schizophrenia having been infected with COVID-19. For instance, all psychiatric units in Lebanon cannot host a patient who has COVID-19 and schizophrenia because he will contaminate the whole floor. We have to think of a psychiatric unit able to admit COVID-19 infected psychiatric patients.

LAMSA: Are there any laws in Lebanon to protect patients with schizophrenia?

Dr. Naja: Yes, there are old laws regarding mental health in general.  There is a new law that has been presented to the parliament but that has not been voted yet.

LAMSA: A final word to our readers: could you choose an artist or a special painting that you relate to schizophrenia?

Dr. Naja: Van Gogh evidently. Or Dali!